What to Watch for: Questionable Claims

PublishedOctober 1, 2015

Questionable claims are worker’s compensation claims insurers refer to the NICB for closer review and investigation because they appear to be fraudulent. According to the NICB’s analysis, insurers reported 3,474 claims as questionable in 2011. That number continues to increase based on data analysis of the first six months’ reported questionable claims.

Insurers may choose to refer a worker’s compensation claim to the NICB as questionable for several reasons. However, according to the recent report, the three most common are claimant fraud, prior injury/not related to work and malingering. These reasons topped the list in 2011, 2012 and 2013.

Claimant fraud is a very broad category that includes knowingly making false worker’s compensation claims, faking or exaggerating injures, filing multiple claims and failing to report income from second jobs. An insurer may select prior injury/not related to work if he believes an employee’s injury occurred prior to obtaining employment or was sustained while off the job. He might select malingering as a reason if he believes the employee is faking or exaggerating symptoms in order to continue collecting benefits after recovery from a legitimate injury.

While employers in big states like California, Illinois and New York suffered the most questionable worker’s compensation claims in total, the rankings changed when the NICB considered claims per 100,000 residents. When analyzed in that way, Delaware topped the list in 2011, Connecticut ranked first in 2012, and Maine led the pack in 2013.

Be prepared:

Consider these three warning signs that may help you spot questionable worker’s compensation claims before they are filed.

Absence of witnesses. An employee attempting worker’s compensation fraud may claim his or her accident occurred when no one else was around.

Monday injuries. Unlike a mid-week injury, it’s possible an accident reported on a Monday may have actually occurred over the weekend.

Repeat claims. One study indicated that 37 percent of employees who filed one worker’s compensation claim would eventually file another.

According to the NICB, worker’s compensation fraud accounts for one out of every four insurance fraud claims in the U.S., costing employers billions of dollars each year. Consult with your insurance professional about ways you can protect your business from questionable worker’s compensation claims.

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